Critical Care Ultrasound Seeing is Believing

Transcription

1 Critical Care Ultrasound Seeing is Believing Philip D Lumb, M.B., B.S., MCCM Los Angeles, California USA

2 Objectives Integrate ultrasound into routine critical care practice Introduce HOLA (Holistic Approach) Explore Technology, Concepts and Capability Discuss procedural Vs diagnostic applications Training and competence in critical care ultrasound

3 The Power Of Context "A newspaper is better than a magazine. A seashore is a better place than a street. At first it is better to run than to walk. You may have to try several times. It takes some skill, but it is easy to learn. Even young children can enjoy it. Once successful, complications are minimal. Birds seldom get too close. Rain, however, soaks in very fast. Too many people doing the same thing can also cause problems. One needs lots of room. If there are no complications it can be very peaceful. A rock will serve as an anchor. If things break loose from it, however, you will not get a second chance."

4 KITE "A newspaper is better than a magazine. A seashore is a better place than a street. At first it is better to run than to walk. You may have to try several times. It takes some skill, but it is easy to learn. Even young children can enjoy it. Once successful, complications are minimal. Birds seldom get too close. Rain, however, soaks in very fast. Too many people doing the same thing can also cause problems. One needs lots of room. If there are no complications it can be very peaceful. A rock will serve as an anchor. If things break loose from it, however, you will not get a second chance. On Being Certain: Believing You Are Right Even When You Are Not, Robert A. Burton, MD, St. Martin s Press, New York, NY 2008 p.5.

5 Consent Compliance in or approval of what is done by or proposed by another Agree Agreement as to action or opinion Webster s New Collegiate Dictionary

6 Informed Based on possession of information Educated Intelligent Webster s New Collegiate Dictionary

7 Landmark An anatomical structure used as a point of orientation in locating other structures A structure (as a building) of unusual and usually aesthetic interest; esp : one that is designated and set aside for preservation Webster s New Collegiate Dictionary

8 Blind A place of concealment; a concealing enclosure from which one may shoot Something to hinder sight or keep out of light To withhold light from Sightless Webster s New Collegiate Dictionary

9 Desiderius Erasmus ( ) In the kingdom (country) of the blind, the one-eyed man is king

10 Evaluation of an ultrasound-guided technique for central venous access via the internal jugular vein in 493 patients Mey,U.; Glasmacher,A.; Hahn,C.; Gorschlu ter,m.; Ziske,C.; Mergelsberg,M.; Sauerbruch,T.; Schmidt-Wolf,I.G.H. The success rate achieved and the frequency of complications are decisively influenced not by the experience of the physician performing the puncture, but by the experience of the physician acting as sonographer. Supportive Care in Cancer :3;

11 Cost Ultrasound Questions? ROI Convenience Time to completion Availability of equipment Complications Significance and reduction Non-insertion related

12 Ultrasound Guidance/Diagnosis Conclusions Practice and experience necessary Subclavian access difficult with ultrasound Most significant catheter complications unrelated to insertion Expensive Ultrasound education required

13 Basic Ultrasound Physics Mechanical pressure waves with periodic propagation through matter. Infrasound >16Hz Audible sound 20Hz - 20KHz Ultrasound 20KHz 10 GHz

14 Terminology Piezo-electric = pressure electric Compression Rarefaction Capable of sending-pausing-receiving Basic ultrasound physics knowledge necessary to manage equipment and process images

15 Characteristics of Sound f- Frequency: number of oscillations per second. l- Wavelength: Distance between two nearest points of equal pressure. v Velocity: The speed of propagation of the waves through a medium. Velocity is determined by the type of the medium. For soft tissues it approximates 1520 m/sec v = f l

16 Attenuators Water Blood Soft tissue (fat) Muscle Bone Air Frequency = 2 Mhz 380 cm 15 cm 1-5 cm cm cm 0.08 cm

17 Appearance Fluid Transudate, blood Exudate, Solid Organ Empyema, thrombus Dense tissue Diaphragm Pericardium Bone Black (Anechoic) Grey (Hypoechoic) (Isoechoic) White (Hyperechoic)

18 Transducers Phased Array Wide frequency range Good far field imaging Cardiac, Abdominal, trans-cranial Small window with accessible footprint Linear Array Near field imaging Small parts: vessels, nerves, organs Curved Array Poor in small acoustic windows Frame resolution rate slower

19 Transducer Arrays Proximal Near field Converging beam Focal Zone Parallel beam Far field Diverging beam Key structures visualized best in Focal Zone

20 Why Ultrasound? Improved reliability Decreased complications Standard of care Specialty definition? Specialty prerogative!

21 Abdominal Examination An important aspect of a clinical ICU evaluation Time sensitive Critical Care Ultrasound Eds. Lumb P, Karakitsos D Elsevier Saunders 2015 Video 1-2

22 Lung Injury Lung consolidation with airbronchogram and associated Pleural effusion. Thoracic Examination Critical Care Ultrasound Eds. Lumb P, Karakitsos D Elsevier Saunders 2015 Video 41-1

23 Lung Point/HFO Pneumothorax Critical Care Ultrasound Eds. Lumb P, Karakitsos D Elsevier Saunders 2015 Video 23-4

24 Point of Care Diagnosis Takotsubo Cardiomyopathy Critical Care Ultrasound Eds. Lumb P, Karakitsos D Elsevier Saunders 2015 Video 27-8

25 Ruptured Papillary Muscle Point of Care Diagnosis Critical Care Ultrasound Eds. Lumb P, Karakitsos D Elsevier Saunders 2015 Video 27-3

26 Courtesy ICCU Imaging

27 Courtesy ICCU Imaging

28 HOLA / Critical Care Ultrasound Head to Toe assessment of the critically ill Specific techniques discussed; generic opportunities available Standardized tests for basic exams Institutional effort required Education Archiving Interpretation

29 Education and Training Teaching Rounds Safety Availability Time Efficiency rapid confirmation clinical diagnosis CCU Clinically Useful immediately relevant Teaching Tool differential diagnosis Critical Care Ultrasound P Lumb, D Karakitsos; Elsevier 2015 Ch 59. S Donaldson-Morgan, M Yee. L Eisen Integrating Ultrasound into Critical Care Teaching Rounds Pp

30 Didactic Education and Training Ultrasound Physics Sonographic Anatomy Knobology Procedural Competence Simulation Continued Learning & Skill Maintenance Training Costs Critical Care Ultrasound P Lumb, D Karakitsos; Elsevier 2015 Ch. 60 M Lamperti; Training and Competence in Ultrasound-Guided Vascular Access Pp

31 ? Critical Care Ultrasound Sparse Data Available on Value of Bedside Physical Exams in ICU Authors emphasize value of comprehensive physical examination in the ICU despite lack of data MONDAY, Aug. 17, 2015 (HealthDay News) -- Data relating to the value of bedside physical examinations in the intensive care unit (ICU) are sparse, according to a review published online Aug. 4 in the Annals of the American Thoracic Society. Thomas S. Metkus, M.D., and Bo Soo Kim, M.D., from Johns Hopkins Hospital in Baltimore, examined the clinical utility of bedside diagnosis in the modern ICU. Experience with CCU demonstrates a positive benefit if used routinely as an adjunct to daily rounds and for specific questions.

32 Routine Clinical Evaluation PE, Labs, XR, Critical Care Monitoring CCM Ultrasound Laboratory PACS Consulting Ultrasound Data Storing & Processing Critical Care Ultrasound P Lumb, D Karakitsos; Elsevier 2015 P. 301 Ultrasound Guided Procedures Endoluminal imaging HOLA Lung & Pleural Ultrasound Basic Advanced Ultrasound Other Techniques 3D, Contrast, Etc Musculo- Skeletal imaging FAST & Abdominal Ultrasound Transcranial Doppler & Ocular US Vascular Ultrasound Complex Evaluations e.g. Volume status

33 References Critical Care Ultrasound Editors; Philip Lumb, Dimitrios Karakitsos Publisher: Elsevier Saunders 2015 ISBN: Critical Care Ultrasound Manual Anthony McLean and Stephen Huang Publisher: Churchill Livingstone Elsevier 2012 ISBN: FOCUS Pocket Guide Focused Cardiac Ultrasound Study 2007 ICCU Imaging, Inc. ISBN: